Diabetes

Question 1

4 signs of DKA

Answer 1

1) Ketones ++ or >3mmol/L
2) pH <7.2
3) Bicarb <15
4) Glucose >11

Question 2

DKA: Maximum potassium infusion

Answer 2

20mmol/h

Question 3

DKA Fluid resuscitation

Answer 3

if SBP <90 500ml within 15 minutes
1L in 1h
1L in 2h x2
1L in 4h x2
1L in 6h x2
if glucose <12 add 10% dextrose

Question 4

DKA: when do you add potassium and insulin

Answer 4

after the first L of fluid

Question 5

DKA insulin regime

Answer 5

normal long-acting insulin +
0.1U/kg/h in a syringe driver (50U in 50ml)
if falls <14 consider 0.05U/kg/h

Question 6

When do you use an insulin sliding scale

Answer 6

T2DM with surgery (NBM)

Question 7

Hyperglycaemia WITHOUT DKA/HHS management

Answer 7

Rehydrate if necessary
Normal insulin +
STAT insulin
T1: 1U decreases 3mmol, aim for <12
T2 0.1U/kg decreases 3mmol, aim for <14

can also calculate correction factor, 100/total daily insulin. 1U will bring down the glucose by this number

Question 8

HHS diagnosis

Answer 8

Glucose >11 (usually >30)
Osmolality >320
Absence of significant ketosis/acidosis
signs of hypovolaemia

Question 9

HHS management

Answer 9

ITU: osm >340, Na >160, pH <7.1, hypo/hyperkalaemia

Rehydrate with 0.9% saline
LMWH and TED stockings
if ketones >1mmol, start insulin 0.05U/kg/h

After 1L reassess glucose, aiming for reduction of 5mmol/L/h
Once glucose stops falling due to fluids, add insulin 0.05U/kg/h
consider potassium in first 24h if <5.5
Stop metformin
Potassium replacement if 3.5-5.5 40mmol/L

if you start insulin too quick you may get CV collapse

Question 10

unconscious hypoglycaemic treatment

Answer 10

STAT IV 150ml 10% glucose/75ml 20% glucose or equivalent

Question 11

Conscious hypoglycaemic with no swallow treatment

Answer 11

2 tubes of glucose gel around teeth

Question 12

Conscious hypoglycaemic with intact swallow

Answer 12

30g fast acting carbs (tablets, juice)

Long acting carb (biscuits, tea)

Question 13

Insulin in elective minor surgery and good glycaemic control

Answer 13

Day before: once daily long acting at 80%, all other insulin stays the same

Day of: adjust usual insulin regime based on Trust Guidelines

Question 14

Insulin in major elective surgery/poor glycaemic control

Answer 14

Day before: long-acting at 80%, all other insulin stays the same

Day of: once daily long acting at 80%. IV fluid infusion of K, Na and glucose. VRII to maintain 6-11mmol/L

Convert back to SC once eating and drinking with no N&V after 30 mins

Question 15

Insulin in emergency surgery

Answer 15

check for ketoacidosis - if ketotic then start DKA protocol and delay surgery if possible

Question 16

which drugs to NOT stop during VRII

Answer 16

GLP1-agonists

All other stopped

Question 17

which drugs to NOT stop in minor surgeries

Answer 17

pioglitazone, DPP4i (gliptins), GLP-1

Metformin if no AKI risk, no contrast, good renal function

Question 18

Example of 
SU
DPP4i
SGLT2i
Thiazolodinedione
GLP-1 agonist

Answer 18

SU: Gliclazide
DPP4i: Gliptin
SGLT2i: Gliflozin
Thiazo: Pioglitazone
GLP-1 agonist: exanatide

Question 19

How often do you check HbA1C

Answer 19

Every 3m until stable

Then every 6m

Question 20

What to check every year

Answer 20

Injection sites
CVD risk factors
Eye disease (fundoscopy and screening)
Kidney disease (ACR)
Foot problems 
Neuropathy problems

Question 21

Medication for diabetics with confirmed nephropathy

Answer 21

ACEi or ATii

Start low and uptitrate to maximum tolerated dose every 1-2w

Question 22

Screening for diabetic foot

Answer 22

At diagnosis and every year (3-6m if moderate risk, 1-2m if high risk, 1-2w if immediate concern)
Self-check every day

SINBAD for ulcers
Site 
Ischaemia
Neuropathy
Bacterial infection
Area (size)
Depth